Doctors face dilemma over compensation from drug companies

Any given week at Giuseppe’s restaurant, local doctors can be found eating free food and drinking free wine.

The meals, paid for in full by drug companies, are a way to entice doctors to listen to industry-sponsored speakers talk about new and current drugs.

Since 2009, one local psychiatrist, Nir Lorant, has received $1,374 in free meals.

But that’s only a fraction of the total he received from drug companies — $60,412 — which included speaking fees and compensation for travel costs, according to a national database compiled by the investigative news organization ProPublica.

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Lorant is not the only local doctor who received free meals or pay for speaking on behalf of drug companies. Nearly 30 of the county’s roughly 700 doctors have benefited, a Tribune review of the database found.

While these marketing practices are defended as educational by many doctors and the drug industry and deemed ethical by a major medical association, critics contend that such practices create a conflict of interest and influence what drugs doctors give their patients.

A look at San Luis Obispo County’s list

According to New York-based nonprofit ProPublica’s compilation of payments made by pharmaceutical companies from 2009-11, 28 doctors in San Luis Obispo County were recipients in one form or another of meals, travel, speaking or research fees. The organization obtained the information from drug company websites as a result of legal settlements with the Justice Department in 2009. The companies on the list account for about 40 percent of drug sales nationally.

Later this year, the federal government will publish final rules on the Sunshine Act, which was part of the 2010 health care reform law, and requires all drug companies to report and track items such as payments to physicians by 2013, said Scott MacGregor, a spokesman for pharmeutical company Eli Lilly.

Physicians who received money from companies that did not report such giving are not included. The list only includes payments of more than $250.

Local recipients

Lorant, a staff psychiatrist for the local state parole office, has received more money from drug companies than any other local doctor, according to ProPublica’s records.

He’s been speaking on behalf of drug companies for about eight years and believes it helps educate doctors on new and existing drugs. Since he started working for the state in 2009, he stopped giving such talks, he said. But according to ProPublica’s records, he was paid to speak for Eli Lilly as late as 2011. From 2009-11, he was paid a total of $60,412, including $26,223 in 2010 and $5,035 in 2011.

The Department of Corrections and Rehabilitation employee rules do not allow staff to receive outside pay unless approved by a supervisor. A CDCR spokesperson could not comment on whether Lorant had received permission before speaking on behalf of drug companies.

Two other doctors topped the list in terms of gifts and speaking fees.

From 2010-11, San Luis Obispo rheumatologist Frank Scott received $58,340 from Eli Lilly. Of that, $53,500 was for speaking, $4,444 for travel and $396 for meals. He received no payments in 2009 and did not reply to requests for comment.

San Luis Obispo psychiatrist Mark Herbst received $5,000 for speaking and $330 in meals from Pfizer in 2010. He could not be reached for comment.

Pfizer, based in New York, tops the Fortune magazine ranking of pharmaceutical companies. Eli Lilly, headquartered in Indianapolis, ranks fifth.

Most local doctors on the list received free meals worth hundreds of dollars. The practice, which appears to be widespread (94 percent of doctors received a gift of this kind, according to a national survey by the New England Journal of Medicine published in 2007), doesn’t bother five local doctors The Tribune spoke to, all of whom have received free meals.

While they recognize that free meals are part of an effort to sell them on certain products, such events with speakers are educational and never influence what they give their patients, they said. The talks are just one way that they educate themselves on new medicine, along with reading journals and speaking with other physicians.

Eli Lilly, for example, has said its disclosure database, which was created in 2011 as part of its Corporate Integrity Agreement with the federal government, indicated it spent $216.5 million on payments and gifts to physicians in 2011.

Doctors respond

Madeleine Hernandez, a doctor at Atascadero State Hospital, said free meals are not unethical because the speakers at the dinners help educate doctors.

“I don’t care what they say or what they feed us — if the product is not good, I will not use it,” she said. She received $355 in free meals in 2010 from Pfizer.

But Bala Krishna Bhat, an internist at Community Health Centers in Arroyo Grande, disagreed.

“There is conflict of interest, definitely,” he said, adding that such free meals could bias a doctor in favor of a specific drug.

According to ProPublica, Bhat received $396 in meals from Pfizer in 2010. Bhat said that is untrue and he never received any free meals.

Marcia Angell, former editor of the New England Journal of Medicine, said free meals, speaking fees and travel create relationships between doctors and the drug industry that amounts to influence peddling at the least. It should be disallowed, she said.

“Drug companies spend billions of dollars seducing physicians so they will prescribe more of their drugs,” Angell wrote in an email to The Tribune.

“It adds to the cost of prescription drugs, and distorts physicians’ judgment,” she wrote. “Of course, it is unethical, and the guidelines, which are strictly voluntary and full of loopholes, are woefully inadequate. There is no way to make it ethical short of outright prohibition.”

Drug companies and the American Medical Association disagree with such contentions.

“Industry can play an important role in providing scientific information about health care products, and physicians have an ethical obligation to help patients and make the best informed choices about their health care without conflicts of interest,” said Steven Stack, one of the AMA’s trustees, in a statement.

The AMA’s ethical guidelines allow modest meals and pay as long as a service is rendered. The guidelines do not approve gifts or payments that expect anything in return.

Pharmaceutical Research and Manufacturers of America (PhRMA), an industry trade group, argues that meals featuring educational talks are good for patients because they give doctors one more tool in understanding medicines.

While PhRMA supports openness, the list of doctors on drug company websites who received meals, travel and speaking fees can and has been misinterpreted.

“We understand that patients may want to know if their physicians take part in peer speaker programs and other activities,” noted Mathew Bennett, senior vice president for PhRMA. But, he added, the list can be taken out of context and not “convey the value of these relationships.”

In 2001, the AMA launched a $1 million campaign to educate doctors about not taking big gifts from drug companies. About $600,000 of the cost was paid for by nine drug makers.

None of San Luis Obispo County’s hospitals bar medical personnel from eating free meals or speaking on behalf of drug companies, according to representatives from the county’s two hospital chains.

Atascadero State Hospital prohibits medical staff from receiving free food, beverages or drug samples during work hours. At least five medical staff received free meals from drug companies in the 2009-11 period, according to the ProPublica list.

Speaking engagement

Wendy Weiss, a primary care doctor in San Luis Obispo, said she was recruited to become a speaker by a drug company representative several years ago and sees no ethical issue with being paid to speak on behalf of drug companies or getting free meals to learn about new drugs.

“It is usually informative,” she said. “It’s advertising, but it’s all accurate information depending on the speaker they bring.”

Weiss said she is paid to take online classes by each company she speaks for as a way to learn about new drugs, and then is paid to give talks at free dinners. Usually, but not always, she speaks about new drugs on the market; they are not always drugs she has prescribed to her patients, she said. She would not identify the last company she represented or how much she was paid. She was not listed in ProPublica’s database.

Lorant said he was recruited because of his years of experience prescribing the drugs he speaks about. Aside from that, the training is rigorous and thorough and often involves days away from home. The talks themselves can also be far from home and take hours to do, he said.

In recent years, the presentations have changed, Lorant said. They’re now more scripted and vetted by industry lawyers, he said, and speakers are no longer allowed to discuss their own experiences with the drugs.

Rene Bravo, a local pediatrician, said drug companies invite him to free dinners at restaurants such as Novo, Giuseppe’s and Lido. He was not listed in ProPublica’s database. Bravo said he only attends such events about once a year when the speaker is of interest to him.

Drug company representatives used to offer doctors free fishing trips, junkets and sports tickets, Bravo said, adding that he never accepted them.

Drug companies still often bring box lunches to doctors’ offices for presentations and give away free drug samples, according to several doctors interviewed by The Tribune.

Jamie Havig, banquet coordinator for Giuseppe’s for example, said drug companies book dinners on average about two or three times a week at one of their two locations. The companies that routinely pay for meals include Pfizer, Bayer and Bristol-Meyers Squibb, about 10 to 40 people are usually invited, and dinners are usually capped at $70 to $100, he said.

Stephen Hawley, a manager at Novo in San Luis Obispo, said his restaurant hosts such meals two to four times a month.

Corrections: An earlier version of this story incorrectly stated the amount of money Dr. Mark Herbst received from Pfizer for meals, travel and speaking. He was paid $5,000 for speaking in 2010 and $330 for meals in that same year.

The story also omitted payments by Pfizer to Dr. Delane Owen Price, who received $9,500 for speaking in 2010 and 2011, $564 for meals in 2010 and $1,277 for travel in that same year.

Also, information in a table below incorrectly said that Dr. Leslie Michel was paid for conducting research for a drug company. Michel was not paid by Eli Lilly for her participation in a clinical trial investigating a new drug; rather, her employer — San Luis Internal Medicine Associates — received the $2,000. Michel’s employer had asked her to participate in the trial.

$1,000 or more: SLO County’s doctor payment registry

According to ProPublica’s “Dollars for Docs” database, 28 San Luis Obispo County medical practitioners received payments from drug companies from 2009-11, a practice considered ethically acceptable by the American Medical Association. The companies include Pfizer, Eli Lilly, GlaxoSmithKline, Bristol-Myers Squibb, Allergen and Cephalon. This list includes those who received more than $1,000. The Tribune attempted to or did contact all but one of the people below. Only one chose to comment.